1. The Place of the Health Department in the City Government. The city and town of New Haven is governed under a charter which provides for the election every alternate year of a Mayor, Controller, Treasurer, City Clerk, Town Clerk, Collector of Taxes, City Sheriff, Registrar of Vital E3tatistics, two Registrars of Voters, and one alderman from each ward. The Corporation Counsel, Police Commissioners, Fire Commissioners and Chief, Director of Public Works, three Park Commissioners, members of the Board of Health, Board of Education, and Board of Charities and Correction, and certain other executive officers are appointed by the Mayor. The municipal budget is framed and all bills against the city approved by a Board of Finance composed of the Mayor, the Controller, one alderman, elected by the Board of Aldermen, and six citizens appointed by the Mayor.

The city and town includes thirty-three wards, one of which, the thirty-second is in the town of New Haven but not in the city. This ward provides its own police and fire protection. The city furnishes this ward with streets, schools and some other improvements. Only a portion of the taxes levied in the thirty-second ward go to the city, the balance being retained by the ward for its own expenditures.

Section 93 of the Charter as amended in 1920 provides that "There shall be a Department of Public Health in said city, under the care and control of a Board of Health, consisting of seven members, one of whom shall be the mayor and two of whom shall be physicians. Said board shall choose a President, who shall be at the head of said Department. All members of said Board shall be residents of said city and shall serve without compensation." The members of the Board are appointed annually to serve for a term of five years. The Board is given ample power under Section 94 of the Charter and it employs the health officer and his staff and fixes their compensation, subject to the approval of the Board of Finance.

The members of the Board of Health for the year 1927 have been as follows; (the date of expiration of the term of each member follows the name); His Honor Mayor John B. Tower, Ex Officio; Mrs. Edward G. Buckland (May 1. 1930), President, William R. Bailey (Feb. 1, 1930), Charles J. Bartlett, M.D. (Feb. 1, 1932), William J. Butler, (Feb. 1, 1928), S. J. Goldberg, M.D. (Feb. 1, 1931), A. J. Mendillo, M.D. (Feb. 1, 1929).

The Chairman of the Board, Mrs. Buckland, and her colleagues have rendered to the city a high quality of voluntary service and Mayor Tower has displayed the keenest and most forward-looking interest in the health program of the city.

It will be noted that New Haven (in conflict with the best trends in municipal government) still has a rather long list of elected officers, including several functionaries whose duties are of a routine administrative nature which should be wholly free from political considerations. The only point in the general plan of organization with which we are here concerned is the maintenance of a separate office of a Registrar of Vital Statistics entirely distinct from the Department of Health. This office has two clerks in addition to the Registrar himself and had in 1926 a budget of $9100.

The registration of vital statistics by an independent lay department of this kind is an unsound procedure for two reasons. In the first place the recording and analysis of mortality returns is a highly technical matter, involving medical judgment as to the significance of assigned causes of death; and in the second place, since the actual use of such statistics is almost wholly in the hands of the Department of Health, it makes for efficiency to have the data collected and analyzed by the experts who are to use them. In the other large cities of Connecticut the transfer of this function of vital statistics registration to the Department of Health has already been accomplished. It would contribute materially, both to economy and to efficiency, if this were done in New Haven.

2. Powers and Functions of the Board of Health. The Board of Health, according to the Charter (Sec. 94) has "all the jurisdiction, power, privileges and duties now by law vested in and imposed upon the town health officers in this state in their respective towns." The town health officers thus referred to in the words of Sec. 2521, Chapter 151 of the General Statutes of the State "Shall have and exercise all the powers necessary and proper for preserving the public health and preventing the spread of diseases." The general powers conferred are, therefore, ample. In addition, the Board of Health, under the Charter, is also specifically empowered to regulate the sale of milk and other food stuffs (the power to license milk dealers being definitely specified) and to abate nuisances.

Furthermore, and most important of all, it is provided that "said board may, from time to time, make such by-laws, rules, regulations and orders as in its judgment the preservation of the public health shall require, to be enforced in the same manner as city ordinances." It is provided of course that the bylaws, rules, regulations and orders shall be "not inconsistent with the constitution or laws of this state or of the United States or with the charter or ordinances of said city;" and that no penalty of more than one hundred dollars shall be imposed for a single violation of any by-law.

All this is in accord with the soundest and best practice. The provision in Section 95 that the Board of Health shall appoint and prescribe the duties of all employees of the Department is, on the other hand, counter to what authorities on municipal health administration generally consider advisable. Experience has shown that it is usually sounder in a large city for the Board of Health to outline broad policies and formulate the sanitary code but to leave administrative details of appointments and duties of individual employees to the Health Officer, in accordance with the sound principle of concentrating administrative power and responsibility in the hands of a single executive. The present Health Officer, however, feels that the system now in force works well and serves as a real protection to him in the exercise of his duties. We therefore refrain from any recommendation on this point, although as the city grows a change in this regard will some day prove desirable.

3. The Sanitary Code. While, as we have seen, the Board of Health has ample power to make "such by-laws, rules, regulations and orders as in its judgment the preservation of the public health shall require," the situation is somewhat complicated by the fact that the Aldermen have from time to time passed ordinances dealing with health matters which of course supersede the regulations of the Board. Certain of these ordinances are distinctly objectionable. Section 345 renders inoperative the control of shellfish taken from the harbor. Section 383 gives a very incomplete list of contagious diseases. Section 384, if enforced, would place an unjustifiable burden upon physicians. Section 392 and 393 are in part archaic. Section 421 is absurd and unreasonable. Sections 429 and 430 are undesirable because they permit and encourage the discharge of fecal matter into the harbor.

The problem of formulating the sanitary regulations of a city is such a complex one that it can only be solved wisely by delegating the duty to a small expert body. It is precisely for this purpose that the Board of Health has been given the power to make and, from time to time revise, regulations for the preservation of the public health. The Board of Aldermen could wisely leave this duty to the Board of Health except in very exceptional instances.

There has been no published collection of the ordinances and regulations dealing with health in New Haven since 1916; many of the ordinances now in force are objectionable or unnecessary and the regulations of the Board of Health are incomplete. It seems to us of the first importance that the Board of Health should prepare a complete and up-to-date sanitary Code in the form of Board of Health Regulations and that the Board of Aldermen should then be urged to repeal all archaic ordinances inconsistent therewith. The new code should not itself be enacted in the form of an ordinance since technical changes will from time to time be necessary and can be made much more easily and scientifically in Board of Health regulations than in aldermanic ordinances.

The Working Rules of the Department, last issued in 1919, are also in urgent need of revision.

4. The Internal Organization of the Health Department. The internal organization of the Health Department is now on an admirable basis, in marked contrast with the situation ten years ago. The Health Officer has under his direction seven distinct bureaus, of Administration, of Communicable Diseases, of Tuberculosis, of Laboratories, of Nursing, of Child Hygiene and of Inspection. The first is of course under the Health Officer himself. The Bureaus of Communicable Disease Control, Tuberculosis and Laboratories have full time directors, while Child Hygiene and Inspection have not. The Bureau of Communicable Disease Control has two divisions, dealing respectively with Venereal Disease Control and Epidemiology. The plan as far as it goes is eminently sound and the creation of a Bureau of Tuberculosis, the most recent addition to the Department, is a step of the first importance. In the future it will probably be desirable to provide for a separate Bureau of Venereal Diseases with a full-time head and for a fulltime head for the Bureau of Child Hygiene; but these problems will be discussed in subsequent chapters.

The staff of the department includes 5 physicians (besides the Health Officer), 23 nurses, 4 dentists, 5 dental hygienists, 3 laboratory workers, 11 inspectors and 5 clerks and stenographers.

The correlations developed between the Health Department and various voluntary agencies in the community constitute a peculiarly admirable feature of the present program. The success of a health officer can be gauged in no better way than by his readiness to welcome, and his effectiveness in securing, the cooperation of other health agencies. It is gratifying to note that the Department carries out important phases of its work through the medium of the Visiting Nurse Association; that the Health Officer is a member of the Health Division of the Community Chest and of the Board of Directors of the Visiting Nurse Association and has an appointment on the staff of the Department of Public Health of Yale University; that the Public Health Committee of the New Haven Medical Society is frequently consulted and serves in essence as an advisory medical board to the Health Department. The work in Child Hygiene has the advantage of the counsel of a School Health Committee. The Bureau of Tuberculosis has a special advisory board and utilizes to the full not only the resources of the Visiting Nurse Association (which handles all its tuberculosis nursing) but also those of the William Wirt Winchester Fund for clinical care of cases and those of the Employees Tuberculosis Relief Association for material relief. The isolation of communicable diseases is cared for on a basis highly advantageous to the city in the Isolation Pavilion of the New Haven Hospital. Through these forms of cooperation the Health Department enormously expands the field of its usefulness to the public.

5. Personnel. Forms of organization are far less important than personality in every phase of human activity; and it is here that New Haven is particularly fortunate. For nearly thirty-five years it enjoyed the services as Health Officer of Dr. Frank W. Wright, a wise and conscientious and loveable public servant, who did much for the Department and whose personality is remembered with affectionate appreciation by all who knew him. On Dr. Wright's death in 1923, the present incumbent, Dr. John L. Rice was appointed to take his place. Dr. Rice was admirably prepared for this post by extensive experience with the Rockefeller Foundation and in state, county and city administrative health work in the United States, and his achievements during the past four years have been such as to place him in the fore-front among the health officers of the United States. The reorganization of the system of milk control, the development of what is probably the best municipal system of tuberculosis work in the United States and the remarkably successful campaign against diphtheria have been, so far, the outstanding events of his administration. New Haven is extraordinarily fortunate in its Health Officer.

In practice, then, New Haven has selected its health officers well and has wisely retained them in office. It should be pointed out, however, that the Charter is woefully deficient in providing the city with adequate safeguards in this respect. It contains no provision either as to the qualifications of the Health Officer or his tenure of office. The Board of Health could, subject to the standards of the Civil Service Commission, appoint any type of individual whatever as Health Officer and change him at any time it desired. It should certainly be provided in the Charter that the health officer of the city should be a physician with special training or experience in the field of public health administration and that, once appointed, he should hold office during good behavior.

Dr. D. M. Lewis, Director of the Bureau of Communicable Disease Control and Miss Margaret J. Barrett, Director of the Division of Nursing are executives of long experience and proved capacity. Mr. P. E. Bransfield, Director of Laboratories was appointed about a year ago as a result of an exacting Civil Service examination and is admirably qualified for his position. Dr. W. B. Soper, Director of the Bureau of Tuberculosis in 1926-1927 and Dr. Herbert Edwards who has recently taken his place are now among the leading experts in their field in the country. The staff of inspectors and nurses attached to the Department are experienced and loyal.

6. Physical Facilities of the Health Department. The New Haven Health Department has for years suffered greatly for the lack of the housing facilities necessary for efficient service. Its headquarters force has been jammed into one room in the City Hall and its laboratories have been located in an attic of the Police Building. During 1926, however, Dr. Rice was provided with reasonably adequate quarters in the City Hall Annex and in 1927 the laboratory was moved into a building of its own at 212 Orange Street in the rear of the City Hall. The headquarters include five private offices and a large room suitable for staff meetings. In general, the facilities now provided seem quite satisfactory for the immediate future.

7. The Health Department Budget. The Health Department budget allotted for the year 1926 was $116,963.33 (original budget $114,255 plus a supplementary appropriation of $2708.33). Of this sum $2051 was transferred to the Department of Public Works for repairs incident to the moving of the department into its new quarters and $1616.63 was turned back into the City Treasury as an unexpended balance, leaving $113,295.70 as actual running expenses. This was subdivided as follows: for Administration, $8334.42; for Communicable Disease control, $19,767.79; for Venereal Disease control, $5412.40; for Tuberculosis, $4927.26; for School Hygiene, $21,302.31; for Public Health Nursing, $25,309.79; for Public Health Laboratory, $6675.05; for Inspection, $21,566.68.

In addition to this fundamental allotment there were assigned from other municipal budgets to the use of the Health Department $1922 for the printing of the Monthly Bulletin and Annual Report and $3593 for automobile service.

In the table below the charges for automobile service have been allocated and the cost of the Inspection Division subdivided as accurately as possible between the three items of milk control, food control and sanitation. The figures are expressed on a per capita basis to compare with the standard budget recently suggested in the American Public Health Association manual on Community Health Organization.

PER CAPITA HEALTH DEPARTMENT BUDGET ANALYZED

BY DIVISIONS AND COMPARED WITH STANDARD.

*Under Registrar of Vital Statistics. Portion of budget ($8947) chargeable to ordinary functions of Vital Statistical Bureau, plus S2500., the estimated cost of vital statistics tabulation in the Health Department.

In interpreting this table it must be remembered that the Standard Budget includes all health appropriations, from private as well as from public sources. Thus, the maternity and infant hygiene work of New Haven is largely performed by the Visiting Nurse Association and the Nev. Haven Dispensary, a considerable part of the Tuberculosis work by the William Wirt Winchester Fund, the Employees Tuberculosis Relief Association and the New Haven Dispensary, a considerable part of the Venereal Disease work by the New Haven Dispensary and two-thirds of the public health nursing by the Visiting Nurse Association.

If we omit these four items and consider only the other ten, in which public funds are not here supplemented by voluntary agencies we find that New Haven is spending but 50 cents per capita as compared with a standard of $1.04. Vital Statistics receives somewhat more than its standard quota. All other items receive less, the most marked discrepancies being noted in the hospitalization of communicable disease about one seventh of the standard, in the Laboratory and Public Health Education and Administration budgets which are but little over one-third of the standard, followed by the budgets for School Hygiene, lTood Inspection and Sanitation which are about half the standard.

Are these low budgets a cause for congratulation or the reverse? Do they indicate wise economy or short-sighted parsimony? The answer differs in the particular instance. In the case of activities such as Food Inspection and Sanitation which are concerned more with public decency than with positive health promotion the low cost is certainly a cause for congratulation. The economy in hospital care of communicable disease will be discussed in a succeeding chapter. In the case of Public Health Education, Laboratory Service and School Hygiene, on the other hand, every dollar spent will bring a large return in the promotion of health and efficiency. We are only just beginning to learn how much can profitably be expended for such activities and all communities are increasing their appropriations as the possibilities are realized. Along these and other lines, as we shall point out in later chapters, it would be eminently wise to provide for substantial increases in the health department appropriation.

The fundamental health department budget for 1926 was, as we have seen, $114,255. For 1927 it was increased to $124,921.66 and for 1928 to $139,050 (plus an additional $6750 for mosquito elimination). The $25,000 increase between 1926 and 1928, is approximately distributed as follows: Administrative, $2000; Tuberculosis, $5000; Venereal Disease, $1000; Laboratories, $3000; Child Hygiene, $5000; Nursing, $6000; Inspection, $3000. It is encouraging to note that the percentage of increase in the budget between 1926 and 1928 is about 22 per cent while the population was increasing 3 to 4 per cent. Thus it appears that the city is gradually making up for its earlier parsimony and is gradually building up adequate machinery for health protection. It will be necessary, however, to continue such increases for some years more in order to ensure the full service which a modern municipality owes to its citizens.

It is of interest to note that the 1928 budget allotments for certain specific purposes work out as follows on a per capita basis.

PER CAPITA APPROPRIATION, 1928.

Street lights and parks are important elements in municipal life; but the protection of the public health should surely rank above them, at least on a level with Charities and Corrections if not with protection against fire and against lawlessness.

There is one minor phase of the city's budget system which deserves attention from the standpoint of municipal bookkeeping. The appropriation of $6750 for mosquito elimination is listed in the 1928 budget under Department of Health and the appropriation of $5000 for services rendered by the Visiting Nurse Association is listed under the Sundries Account; but neither of these appropriations was made and neither is controlled by the Department of Health. Both items represent entirely wise expenditures but both are appropriations for public health purposes and should be handled through the medium of the Department.

8. Conclusions and Recommendations. In general, the organization and administration of the Health Department seems to be admirable. In order that it may always remain so, it would seem desirable to safeguard the qualifications and tenure of office of the Health Officer by Charter Amendment, though the need is not at present immediate. The most serious defect in the present plan of organization is the separation of the registration of vital statistics from the Health Department where it properly belongs. We shall point out in subsequent chapters lines of urgently important investigation which could easily be performed in this bureau without additional cost if it were properly organized under medical direction.

It seems essential for the most efficient sanitary administration that the Sanitary Code and Working Rules of the Health Department should be revised and brought up to date and that obsolete and conflicting city ordinances should be repealed.

Finally, the Budget of the Department should be substantially increased as indicated in subsequent chapters particularly along the lines of child hygiene, venereal disease control and public health education and that all city appropriations for health purposes should be routed through the Health Department.

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